1. society
2. welfare
3. healthcare
4. hospital

Loughborough University
Institutional Repository
EuHPN Workshop: One
Problem, Many Solutions:
how to make healthcare
infrastructure deliver for
society
This item was submitted to Loughborough University’s Institutional Repository
by the/an author.
Citation: MAHADKAR, S. ... et al (eds), 2010. EuHPN Workshop: One
Problem. Many Solutions: how to make healthcare infrastructure deliver for
society. Stockholm, May 5-7, 2010. Loughborough : Loughborough University,
2010.
Additional Information:
• This report is also available online at: http://www.haciric.org/static/pdf/publications/EuHPN%20Work
Metadata Record: https://dspace.lboro.ac.uk/2134/14731
Version: Published
c European Health Property Network (EuHPN); Health and Care
Publisher: Infrastructure Research and Innovation Centre (HaCIRIC); Loughborough University
Please cite the published version.
Stockholm, May 5-7, 2010
EuHPN Workshop
One Problem, Many Solutions: how to
make healthcare infrastructure deliver
for society
Edited By: Sameedha Mahadkar, Grant Mills, Jonathan Erskine and
Andrew Price
Stockholm, May 5-7, 2010
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Stockholm, May 5-7, 2010
EuHPN Workshop
One Problem, Many Solutions: how to make healthcare deliver for society
Edited By:
Sameedha Mahadkar, Grant Mills, Jonathan Erskine and Andrew D.F. Price
Health and Care Infrastructure Research and Innovation Centre (HaCIRIC),
Loughborough University; European Health Property Network, Durham University
Published in England by:
Department of Civil and Building Engineering
Loughborough University
Loughborough
Leicestershire
LE11 3TU
UK
Any errors or omissions in this report are the responsibility of the editorial team.
The speakers represented in this report have given permission to use the
illustrations contained herein.
Copyright © European Health Property Network (EuHPN); Health and Care
Infrastructure Research and Innovation Centre (HaCIRIC); Loughborough University.
ISBN 978-1-897911-37-2
© 2010, European Health Property Network (EuHPN); Health and Care Infrastructure
Research and Innovation Centre (HaCIRIC); Loughborough University
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Contents
i. Foreword .............................................................................................................................................. v
ii. Summary ........................................................................................................................................... vii
1. Tools and Methodologies for Planning - Introduction ........................................................................ 1
1.1.
Making Healthcare Infrastructure Deliver for Society ............................................................ 1
1.2.
Tools and Methods for Planning: Locum AB ........................................................................... 2
1.3.
Sweden’s Healthcare: Structure and Organisation ................................................................. 4
2. Tools and Methodologies for Planning – parallel sessions A and B .................................................... 6
2.1. The New Karolinska Solna University Hospital – The New Centre for Integrated Specialised
Care, Research and Education ............................................................................................................ 6
2.2.
Master Planning in the 21st Century: NKS, Huddinge and Södertälje Hospital ....................... 8
2.3.
The Concept Program ........................................................................................................... 10
2.4. One New Hospital per Decade: Is there a Swedish Way? A History of Planning Health
Facilities ............................................................................................................................................ 12
2.5.
Decision Support for Hospital Reconfiguration: New Guidelines and Tools ........................ 14
2.6.
Innovation in Healthcare Infrastructure Planning in Italian Regions – Tools and Methods . 16
2.7.
French Regional Planning: To Build New Hospitals or to Renovate Existing Structures? ..... 17
2.8. Clinical Space Calculator: How to Move towards Generic Healthcare Spaces and Fit the
Facilities to the Activity ..................................................................................................................... 18
3. From Planning to Realisation: how to get ‘there’ from ‘here’ .......................................................... 19
3.1.
The Ex-Ante Evaluation Methodology in Regional Planning: The Italian Case ..................... 19
3.2.
The Hospital and its Role in Economic Development ........................................................... 20
3.3. The North Tees Momentum Project: Care Pathway Planning and the Consequences for the
Health Estate ..................................................................................................................................... 21
3.4. Integrated Infrastructure Planning in UK and Sweden: Two Perspectives on the Context and
Tools for Strategic Development ...................................................................................................... 23
3.5. Bringing Capital into the Equation: Building a Health System where Capital Goes with the
Diagnosis ........................................................................................................................................... 24
3.6. Design Dialogues: A Collaborative Method for Design Driven Innovation and Specification
in Front End Planning ........................................................................................................................ 26
4. Challenges and Opportunities in planning and delivering the health estate ................................... 28
4.1.
How Healthcare Infrastructure can and should contribute to making a better civil society 28
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4.2. Barriers to Innovation in Public Sector Procurement - the Case of Low Carbon Healthcare
Buildings ............................................................................................................................................ 28
4.3. The Adverse Effects of the Absence of Return on Investment (ROI) Calculations in the
Public Sector in General and Healthcare in Particular ...................................................................... 29
4.4.
Rebalancing Care Infrastruture in Hungary: Barriers to Success .......................................... 30
4.5. Europe Matters: A Reflection of Trends and New Directions in European (& EU) Capital
Investment Strategies ....................................................................................................................... 31
5. Recommendations ............................................................................................................................ 36
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i. Foreword
The European Health Property Network is a not-for-profit trust, established in 2000, which brings together
European government health estates departments and agencies, R&D organisations, academic centres and
professional associations with interests in health facility planning, design, and financing. The network holds
regular events for member organisations, and collaborates with a number of other organisations working in
the same field. Members share knowledge and practice with each other through personal interaction and via
the organisation’s website, and on occasions they singly or collectively commission original research on topics
of interest to them.
The most regular and important EuHPN event is the network’s annual workshop, held each year in a different
European city. Recent workshops have been held in Durham (England), Belfast (Northern Ireland), Paris
(France), Budapest (Hungary), Oulu (Finland), Florence (Italy), Edinburgh (Scotland), Lisbon (Portugal) and Oslo
(Norway). In 2010 the EuHPN Board accepted the kind invitation of Locum AB to host the workshop in
Stockholm, Sweden, in collaboration with Karolinska Institutet. This report is a record of that event, which
th
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took place from 5 to 7 May, 2010. Readers should note that this report is not a ‘proceedings’; that is, the
text has been prepared by researchers who participated in the 2010 workshop, not by the speakers
themselves. Speakers have reviewed the text, however, and have given permission to use their illustrations,
diagrams, and other graphics.
The themes for EuHPN workshops vary from year to year, and tend to reflect trends that are emerging in
health capital asset investment. Sometimes the emphasis may be on planning the health estate at local,
regional, or national level; at other times members are more interested in the architecture and design of
health buildings, or the financial mechanisms available to secure investment. For the 2010 workshop, the
EuHPN Board determined that the theme should be ‘Why healthcare infrastructure has to deliver for society’,
and that the most appropriate way to approach this would be the contrast between the recent period of ‘big
bang’ investment in health infrastructure, and the emerging sense that incremental development may be the
way forward. Whichever approach is taken, health infrastructure ultimately has to serve the health needs of
country populations, and has to respond to the demands of clinicians, managers, politicians and the public.
To examine the theme of ‘big bang’ versus ‘incremental’ development of the health estate, speakers were
invited from a range of disciplines, organisations and countries, and were marshalled into a programme that
had three main sub-themes:
Tools and methodologies
What does the current crop of planning instruments tell us about how best to tackle the challenges of the
health estate? Speakers presented their experiences of planning health facilities at local, national and
international level, with emphasis on evidence-based methods for deciding what to build and where to build it.
From planning to realisation
Having examined the demographic, epidemiological, financial and organisational contexts around provision of
health facilities, what is the best way to move from the planning phase to a successful project? This section of
the workshop introduced some practical case studies of individual hospital projects, regional reconfiguration
of health care infrastructure, and the links between care pathway development and the built environment.
Challenges and opportunities
The planning has been done; a project is underway – what are the barriers to implementation; how can we
ensure a successful project? The closing session of the workshop looked at the importance of reflective,
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iterative planning, the contribution of innovative procurement, and the difficulties of rebalancing care
infrastructure in some countries.
The 2010 EuHPN workshop would not have been possible without the support of a number of organisations.
Firstly, thanks are due to EuHPN member organisation Locum AB, the property management company owned
by Stockholm County Council. Locum acted as hosts for the event, and their staff were unfailingly helpful
during preparations and the workshop itself.
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This year’s workshop included a 200 anniversary celebration of the founding of Karolinska Institutet, which
explored how that institution sees its developing role in cutting-edge medical and clinical research. Speakers
from Sweden, Germany, UK and Netherlands discussed how medical and clinical research relates to the
healthcare offered to patients at the New Karolinska Solna Hospital, and to the wider world. Many hospitals
have important roles as education centres, and since these are costly to build and maintain, they need to show
how their work will improve healthcare for patients and the population in general. Presentations during
‘Karolinska Day’ examined the importance of trans-national cooperation in research and education, how best
to plan for hospital-based research facilities, and optimum designs to enhance teaching and learning in clinical
settings.
Thanks are also due to two workshop sponsors. Bdpgroupe6, a leading Anglo-French architecture practice, has
a long association with EuHPN and the annual workshop, and was welcomed back as a sponsor in Stockholm.
This year saw another of Europe’s leading architecture practices – White arkitekter AB – also become a
workshop sponsor. The contributions of both sponsors, in providing speakers and practical support for the
event, were extremely welcome.
EuHPN is also very grateful to Sameedha Mahadkar, Grant Mills and Professor Andrew Price of HaCIRIC
Loughborough University, Department of Civil and Building Engineering. They have jointly prepared the great
majority of the text in this report and have spent much time in selecting appropriate and relevant illustrations.
HaCIRIC (www.haciric.org) is an EPSRC UK collaboration between Imperial College London and the universities
of Loughborough, Reading and Salford. Its work focuses on the underlying built and technical infrastructure for
healthcare, and the interaction between this infrastructure and change and innovation in care services.
HaCIRIC is currently working with over 135 collaborators, including health and social care authorities, private
sector companies and non-profit organisations in the UK and abroad.
Jonathan Erskine
Executive Director, European Health Property Network
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ii. Summary
Jonathan Erskine, Executive Director, European Health Property Network; Researcher at the Centre for Public
Policy and Health, Durham University
Even with the guidance of a single, overarching theme it is no easy matter to bring together a disparate group
of people, comprising health planners and architects, health capital finance experts, health policy academics,
and health facility professionals, and then expect a straight-forward narrative to emerge from their various
presentations and discussions. In fact, thanks to input from the EuHPN board and pre-workshop conversations
with the speakers and attendees, the 2010 Stockholm workshop enjoyed a remarkable degree of coherence.
John Cole, Chair of the European Health Property Network, set the scene in the workshop’s opening session by
posing a series of questions around the issue of ‘big bang’ versus incremental development of healthcare
facilities. The following commentary follows these questions, and attempts to use them to find some emerging
conclusions and observations from the workshop presentations.
Can we consolidate into fewer facilities?
Do we optimise the possibilities of reuse/renovation of existing accommodation before opting for new
build?
These paired questions were at the heart of a number of workshop presentations.
Gunilla Hogbom (Managing Director, Locum AB), for example, outlined the drive towards more efficient use of
health infrastructure in Stockholm County, better suited to the current and future demands of the Swedish
healthcare system. As property management agents for Stockholm County Council, Locum has rationalised the
health estate over the last 18 years, such that around SEK 7.4 billion of publicly owned property – including a
large proportion of health property – has been sold. Locum’s current projects are a mix of extensions,
renovations to existing healthcare facilities, and some new structures. Göran Stiernstadt, MD for Healthcare
Issues at the Swedish Municipalities and Counties Organisation, also noted the recent reduction in the number
of full-scale emergency hospitals in Sweden from 13 to 7, as well as a significant trend towards home-based
care. And even in the case of the New Karolinska Solna Hospital – a notable example of a ‘big bang’
development – Professor Lennart Persson commented on the project’s aims to consolidate existing, outmoded
buildings.
Agneta Philipson (Locum AB) tackled this question from a technical perspective. The Property Development
Plans for the hospital facilities currently managed by Locum have been developed to look at the long-term
sustainability of existing accommodation, with emphasis on looking ahead to future clinical and technical
developments, and how healthcare buildings can be designed now to allow for maximum future adaptability.
In some cases, the analysis phase of a Property Development Plan may indicate the need for significant
investment in new construction (e.g. the Södertälje Hospital), whereas in other cases there is room for use of a
refurbishment strategy.
The presentation on the Momentum: pathways to healthcare project (Carole Langrick, Ali Wilson) was
evidence of how the various sectors of a local health economy can plan collectively to reconfigure the health
estate. Momentum aims to make major changes to the way that health services are provided to people in
North Tees, UK, and its central philosophy is to provide as much care as possible closer to home. This approach
proposes a reduction, compared with existing provision, in the number of acute hospital beds, but balanced by
an expanded primary, community and home care service. This service plan has required a fundamental
reassessment of how best to use existing healthcare facilities, the planning of a new hospital (to replace
existing buildings), and commitment to some new integrated care centres. One of the major barriers to
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successful implementation of a reconfigured health estate has traditionally been the reluctance of different
organisations (hospitals, family doctors, community services) to accept that planners should take a holistic
view of the entire health economy in a locality, and that disinvestment – as well as investment – is a necessary
part of the equation. In the case of Momentum there is evidence that this barrier has been at least partially
overcome, and that clinicians and managers from different organisations have begun to act collectively and to
see the bigger picture.
The same trend in thinking emerged from the presentation on regional planning in Italy (Simona Agger), which
described a movement towards rationalisation of the number of smaller hospitals and greater provision of
home care. As with Momentum, the tools available to Italian health planners now include detailed information
on the expected outcomes of capital investment programmes, both in terms of population health and lifecycle
costs. And in Norway, Marte Lauvsnes (SINTEF Health Research) described the growing movement to look
again at older hospitals with a view to refurbishment and reconstruction, in contrast with the country’s recent
history of large-scale, new build hospitals. Planning tools and processes have latterly been developed to cope
with the ‘big bang’ approach to hospital development, but it is now recognised that these have to be reviewed
and re-thought in order to be relevant and useful for smaller scale projects, and to bring into the equation the
same considerations of future flexibility and adaptability.
There was some interesting contrast here with the trends in France. Bertrand Bailleul (Forum Europeen; CEO,
Hospital Saint Jean des Gresillons) described the enormous infrastructure investments that have been taking
place over the last 10 to 15 years, both in hospital buildings and in supporting IT systems. Although the
planning processes were intended to take account of priorities in terms of population health and clinical need,
as well as financial viability, it was clear that there had been a lack of evaluation once projects were underway.
The result has been that some hospital organisations had found themselves in financial difficulties.
Can we reduce energy usage?
Healthcare buildings generally consume very considerable quantities of energy, and when we take into
account the energy costs involved in transporting staff, patients, equipment and supplies around the various
2
elements of a healthcare system, we see that this sector contributes significantly to Europe’s CO output.
Given the current financial constriction that many countries are now facing, it was interesting to note that few
speakers directly addressed the issue of energy efficiency strategies. One exception was Barrie Dowdeswell
(Research Director, European Centre for Healthcare Assets and Architecture, ECHAA), who gave a panEuropean perspective on strategic health capital investment projects, and in doing so pointed out that the EU
Commission’s Europe 2020 agenda includes specific mention of policies that will promote a more resource
efficient, greener and more competitive European economy. However, most of the speakers who presented
planning tools and methodologies appeared to assume that these are ‘policy neutral’ i.e. a strategy or project
plan that addresses the need to use less energy, or to use it more efficiently, will only emerge if those aims are
specified in the input conditions. At one level this is of course true. Those who are charged with constructing
or renovating health care buildings take their lead from guidelines and directives, and often work within very
2
strict financial parameters. However, if European nations are to meet the objective of reducing CO emissions
through less wasteful use of hydrocarbons, it could be argued that this requirement should be built in – preinstalled – in the set of assumptions used by planners at all levels. At the very least, this consideration should
perhaps carry more weight when considering whether to build new or to renovate and/or reconfigure existing
structures.
The presentation on Low Carbon Healthcare Buildings (Angus Hunter, LCB team) certainly addressed two
2
particular, linked aspects of the debate on energy use and CO targets: procurement practice and innovation.
Health infrastructure projects often begin with ambitious expectations of zero carbon or ultra-low carbon
construction and maintenance, but somewhere between the initial concept and the final, built solution, these
aims are often diminished in scope. Procurement procedures for health infrastructure are traditionally risk
averse, and often bound by governmental guidelines and rules. In such circumstances it is not easy for health
facility managers to persuade boards and the supply chain that carbon reduction measures should be given a
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higher priority, and that truly innovative, forward-looking solutions should be part of a healthcare
organisation’s procurement strategy. The LCB presentation concluded that the EU Commission is aware of this
barrier to better energy management and is actively promoting networks that will share best practice and help
to convince procurers and suppliers that low carbon construction in the health sector can be more than
rhetoric.
Reductions in hospital energy costs are often associated with technical solutions: more efficient heating and
lighting systems, better insulation, etc. However, one workshop presentation (Gianluca Ghiselli, Asti Azienda
Sanitaria Locale, Italy) provided evidence of what is possible by taking a more holistic approach. Asti hospital’s
PEH programme (Project, Economy, Health) has a major component which concentrates on the energy costs
associated with food supply, by significantly increasing use of locally sourced food and involving patients in its
production. This element of the PEH programme also aims to stimulate the local economy and provide social
activities for the Asti community. This ‘multiplier effect’ was elaborated further in the presentation from Alan
Hennessy (bdpgroupe6), which included a comparative analysis of the economic contribution of the healthcare
sector to job creation and GDP.
Do we specify our buildings appropriate to their use?
Do we truly incorporate flexibility and appropriate standardisation or modularisation?
These linked questions are central to planning for health capital investment and infrastructure development.
Recent reports on this area (e.g. ‘Investing in hospitals of the future’, 2009, WHO; Systematisation of clinical
care and health capital planning, Dowdeswell B and Erskine J, in ‘Changing Clinical Care, 2008, Radcliffe
Publishing) have suggested that it is becoming increasingly difficult to ensure that health facilities avoid being
constructed to support service models that are out-of-date as soon as the buildings are complete. In some
cases this may be due to the financial mechanisms used to pay for health facilities (e.g. the restrictive nature of
contracts with private finance consortia), in other circumstances planners and designers find it difficult to
anticipate future trends in medical technology or clinical practice. The consequences of failing to provide a
building that can adapt to changing health service needs can be expensive, not only in cost, but also in terms of
the quality of healthcare provided.
In any case, methodologies that help to avoid or mitigate this pitfall – even partially – must be welcomed by
policy makers, health facility managers and health service planners, and the workshop heard from a number of
speakers who are using and developing just such tools. Anders Lövefors, for example, described the ‘Concept
Program’ that is being used by Locum AB to plan projects for emergency care, acute care, maternity and
surgical services, and imaging processes across a number of different hospital sites. In broad terms, the
Concept Program obliges planners to look carefully at the lifespan of health facilities in terms of the service
elements that they are expected to support, and to build in these considerations at an early stage in the design
process. Jonathan Millman (Department of Health – Estates and Facilities, UK) and Ashley Clough (Parallel
Interactive) presented a prototype tool – ‘The Scheduler’ –which explicitly links the costs of the spaces used in
health buildings with the income generated by the activities that take place in them. This tool is being further
developed to emphasise the possibilities of creating generic spaces that can be flexibly adapted to different
clinical and medical uses, and to create a strategy for disinvestment in under-used or redundant facilities.
Grant Mills (Loughborough University, UK), Phil Astley (MARU, UK) and Gorän Lindahl (Chalmers University of
Technology, Sweden) compared the master planning approaches in the UK and Sweden. This presentation
took a more strategic view of health estates development, and concluded that open scenario planning – to
anticipate future changes in clinical and service models – was still underused in both countries. In particular,
there was a pressing need to pay more attention to the scale and distribution of health care facilities. The
speakers commented that master planning in Sweden has traditionally tended to put more emphasis than in
the UK on integration of health buildings with other elements of the social fabric. This was reinforced by Anna
Montgomery (White Arkitekter, Sweden) who covered the development and use of standardised building
units, but also the way in which Swedish planning often uses healthcare building projects to reinvigorate urban
spaces.
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Do we optimise procurement skills to reduce cost?
Compared with the development of upfront planning processes and high level strategy and vision for new
healthcare buildings, procurement practice is relatively neglected by politicians and even by health system
planners. Perhaps it is seen as something rather dull – a technical area that simply involves following rules and
guidelines. In practice, however, procurement in the widest sense can have a very significant impact on the
success of a healthcare building, as judged by whether it truly supports the clinical needs of a local population,
and whether the building really can adapt to future demands.
If more healthcare organisations were willingly to critically examine risk, we might see different procurement
decisions being taken, as illustrated by the case studies discussed in Barrie Dowdeswell’s presentation. We
might even see greater impact from Return on Investment (ROI) thinking, as outlined by Dr Arne Bjornberg
(Health Consumer Powerhouse). Dr Bjornberg argued that most European healthcare organisations were
poorly placed to understand the effects of not investing, and often saw this as a cost saving rather than an
opportunity missed. Reduced costs may come from innovative, strategically aligned procurement, but rarely
from refusal to adapt to changing service needs. In the particular case of capital investment costs, Rhonda Kerr
(Rhonda Kerr Associates, Australia) raised the interesting example of Australia’s recent decision to move
towards funding based on outcomes rather than inputs, and to include a wide range of elements – comprising
clinical services, imaging, pathology, pharmacy, ICU and patient hotel – in DRG payments.
Some final observations
The 2010 EuHPN workshop brought together a mix of healthcare planners, architects, academics, and capital
investment experts from around a dozen different countries. The central theme -Why healthcare infrastructure
has to deliver for society – now seems better chosen than ever, given the major reductions in public and
private sector expenditure that are now being implemented across Europe. If healthcare organisations can’t
find a way to do more with less they will fail in their primary objective of improving healthcare and population
health, since they all face mounting pressures from increased costs and squeezed revenues. In such
circumstances, decisions about whether to build anew or to renovate, to invest or disinvest, and how to best
match facilities to present and future need, are paramount. The summary of Professor Peter Frost’s
presentation on ‘Design Dialogues’ sums up the required direction of travel very well:
The key challenges in healthcare are to better capture and describe client and user needs in a complex
environment and to support change and organisational innovation through facility planning.
The challenges mentioned in the above quotation are present in all countries, but in some they are certainly
more acute. The Stockholm workshop concluded with an expert analysis of the barriers to successful
rebalancing of Hungary’s healthcare infrastructure, delivered by Dr Miklos Szocska (Health Service
Management Training Centre, Semmelweis University, Budapest). Here was a clear example of public servants
who know what is needed, but who have to face numerous inhibitors: political influence on resource
allocation, the malign effects of informal payment systems, a dissatisfied healthcare workforce, and an
inefficient and inequitable central system in charge of capital investment and master planning.
While Hungary’s difficulties may be salutary, they are not unique, and they are reflected to a greater or lesser
extent in many other European nations. It is for this reason that organisations such as the European Health
Property Network (EuHPN), the Health and Care Infrastructure Research and Innovation Centre (HaCIRIC) and
the European Centre for Healthcare Assets and Architecture (ECHAA) will continue to support the knowledge
exchange and research that can at least help to illuminate the best way to ensure that healthcare
infrastructure can deliver for society.
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1. Tools and Methodologies for
Planning - Introduction
1.1.
Making Healthcare Infrastructure Deliver for Society
John Cole, Chair of the European Health Property Network (EuHPN) and Chief Executive of the Health Estates
Investment Group, Northern Ireland initiated the workshop with some remarks on why healthcare
infrastructure has to deliver for society.
Many governments are heavily indebted and there is reduced tax income due to the current recession. Within
such an environment, it is difficult to secure the required capital to build and run new projects. The key issue is
to determine how strategic planning can respond to these challenges. Is the current model of acute hospital
centred services sustainable? How can health services deliver the most effective and affordable treatment and
care? What are the costs involved in providing and maintaining the current hospital infrastructure? Is the
physical footprint too big from an affordability perspective as well as from a sustainability perspective?
In response to these issues, health providers are considering solutions such as the centralisation of specialist
services into fewer larger hospital facilities which function as centres of excellence, combined with the
increased delivery of a range of less complex services in community settings that were only previously
available in hospital settings. Improved connectivity between the sectors is critical to the success of this model
and in particular there is a need to have better IT systems including integrated patient record systems. This
model is intended to achieve earlier and less expensive diagnoses and interventions being carried out closer to
home and the avoidance of unnecessary hospitalisation.
In light of the funding pressures and the ever evolving models of care there is a view that capital investment
options should re-consider the appropriateness of large hospital developments which may not have the
flexibility to respond to changing practice and funding issues. Modernisation, extension and/or reconfiguration
of existing facilities may represent better value-for-money in the longer term. As part of an estate
rationalisation process, planners need to consider the following issues:
Can we consolidate into fewer facilities?
Can we reduce energy usage?
Do we optimise the possibilities of reuse/renovation of existing accommodation before opting for new
build?
Do we specify our buildings appropriate to their use?
Do we truly incorporate flexibility and appropriate standardisation or modularisation?
Do we optimise procurement skills to reduce cost?
The key trends in the location of services are depicted in Figure 1. There has been a movement of out-patient
diagnostics and treatments from acute specialist to community settings, whereas complex specialities are seen
moving toward centres of excellence.
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Figure 1. Location of Service Trends
Although the trend in recent years has been to provide nucleus hospitals, which provide the ‘big bang’
solutions; it is important to consider the affordability of such schemes. There has been some increasing
reluctance on the part of PFI consortia and private companies to take on risks associated with large scale
developments. Instead, perhaps there is a need to have smaller scale projects that are flexible, add value and
are part of a larger coherent master plan. It is important to consider if an incremental phased model of smaller
scale developments will facilitate more flexibility to cope with rapidly changing development needs; and the
cost of compromise for moving from larger to smaller projects. Capital investment could act as the catalyst for
change in the current environment, where we are entering the era of ‘small bang’.
1.2.
Tools and Methods for Planning: Locum AB
Gunilla Högbom, Managing Director, Locum AB, Sweden.
This presentation began with a brief background to Stockholm’s healthcare demographics and elaborated on
the Swedish healthcare system. Stockholm County Council serves 2 million inhabitants (21% of the Swedish
popultation) and has 26 muncipalities. This is paid for by the tax payer and had a revenue in 2009 of SEK 68
billion. Stockholm County Council employees 7,250, 000 doctor visits and 7,610,000 other visits (home care,
district nurses, antenatal clinic, child health care clinic, physiotherapists etc.) and they provide some 6,000
beds.
Healthcare services are provided through an administration which purchases healthcare from different
providers. These can be companies or other organisations owned and run by the county council or private
companies. At the moment 30 % of the emergency services and 50 % of the community healthcare are
provided by private companies.
Locum AB is one of Sweden’s larger property management companies with a property portfolio of about 2.1
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million m in the Stockholm region and is owned by Stockholm County Council. Major tenants include
healthcare institutions in the Stockholm County. When the company was set up in the earlys 90’s to manage
and develop the real estate portfolio each unit had its own management; but now it has professional
integrated management of all properties. The graph below (Figure 2) shows the rental costs as a percentage of
the overal healthcare costs from 1992 onwards. The rental costs have gradually declined from 18 % and are
now fluctuating around 7%. Since 1992 Locum has sold properties worth SEK 7.4 billion along with
2
development rights for about 5,000 new homes and around 1 million m in total floor area. This was a
profitable venture for both the county council and the tax payers. Currently, more healthcare is provided than
18 years ago on a smaller footprint. Locum´s organsiation consists of 200 personnel. They have chosen not to
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own their resources for technical management; instead they are procured by competative tender in the open
market. Their markets include community, emergency and university hospitals.
18
15
12
9
6
3
0
-92
-94
-96
-98
-00
-02
-04
-06
-08
Figure 2. Rental Cost Since 1992
Locum’s project catalogue consists of projects at an estimated cost exceeding SEK 5 billion. The largest include:
Emerges (Figure 3: an extension for Stockholm South General Hospital: operating suite, emergency
department, maternity/obstetrics and sterilisation unit. It has a gross floor area of 35,000 sq meters),
Danderyd (Figure 4: a new acute-care building for Danderyd Hospital. It has a gross floor area of 48,000 sq
meters) , Innovation (Figure 5: a new building for surgical operations, intervention, academic research and
business in collaboration with Karolinska University Hospital in Huddinge) and Helix (Figure 6: a new forensic
psychiatry facility in Flemingsberg, with an investment of SEK 762 million and estimated completion in 2012).
Figure 3. Emergens Hospital
Figure 4. Danderyd Hospital
Figure 5. Innovationsplats (innovation site)
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Figure 6. Helix
Stockholm, May 5-7, 2010
The following table depicts how the various Stockholm county council healthcare premises are utilised.
Net floor area, thousands of m2
Percentage
Rental income, SEK M
University hospitals
490
35
925
Emergency hospitals
294
21
484
Type of tenant
Dental care
13
1
19
Other healthcare
241
17
425
Other county council activities
59
5
70
Total county council activities
1,097
79
1,923
Private emergency hospitals
44
3
83
Municipalities
29
2
49
Other healthcare
52
4
94
Other activities
53
4
69
Total other activities
178
13
295
1,275
92
2,218
106
8
7
−
1,388
100
Total rented
Vacant
Other, unrentable
Total Stockholm County Council Real Estate
The following tables depict the Stockholm County Council Real Estate in brief.
Financial details, SEK M
Rental income
Operating profit before depreciation
Profit for the year
Property purchases
Property sales
Book value of properties
Cash flow
1.3.
2009
2,316
1,258
401
1,104
70
10,422
201
2008
2,224
1,348
461
1,149
217
10,363
15
Property details
Number of properties and leaseholds owned
Total floor area, thousands of m2, TFA*
Net floor area, thousands of m2, NFA**
2009
49
2,102
1,387
2008
51
2,100
1,388
Vacant net floor area, thousands of m2, NFA**
124
112
Occupancy rate, strategic properties, %
93
94
Occupancy rate, all properties, %
91
92
Sweden’s Healthcare: Structure and Organisation
Göran Stiernstedt, Managing Director for healthcare issues, Swedish Municipalities and Counties Organisation
In Sweden, county councils are responsible for delivering healthcare as well as transport planning and regional
development. 30-40% of the budget of a municipality is dedicated to social services and 70-80% includes
education along with spatial planning, waste and refuse and other support services. About 15% of income tax
is dedicated to healthcare; this is paid to the local councils and muncipalities. A tax equalisation system exists
to enable county councils and muncipalities to have equal economic conditions for their activities,
independent of income factors and structural factors that cannot be influenced. The Swedish healthcare
system is characterised by an emphasis on equity and a comprehensive cover that accounts for the entire
population. It is planned using quasi-market mechanisms with tendencies to decentralise (20 County Councils
and 290 Municipalities). Key finance details include:
Healthcare is publicly funded – 80 % local taxes, 17 % grants from the central government
Patient fees comprise 3 % of the financing
Private funded healthcare is less than 1%
Patient fees for GP visits are 100-150 SEK, these are higher for certain specialities. Care is free for children up
to 20 years old and also for patients with chronic diseases. The maximum total annual cost per adult is 900
SEK. Patient’s fees as part of total costs for prescription drugs are just above 20%. These prescription costs
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Stockholm, May 5-7, 2010
vary depending on the accumulated costs of drugs, where patients can pay 10% to 50% of the costs in a 12
month period. Dental care has limited subsidisation. Private care providers are common at a primary level with
contracts with the county councils (25%), although they are uncommon at a whole system level (only 10 %).
Recently there has been a new change in the legislation which allows hospitals to establish businesses with
private care providers within primary care, making it possible to mix public and private financing. It is also
obligatory for the county council to allow for the same.
The key element of the Swedish health system is decentralisation, which serves as the main strategy for
improvements, in combination with guidelines, benchmarking and support from national agencies. Further
comparisons of outcomes and performance of the various counties within Sweden for medical results (MSRA)
infections, breast cancer, stroke care, hip replacement, patient experience, time related availability and costs
related with different treatments were also presented. It was noted that there has been a major reduction in
full-scale emergency hospitals from 13 to 7 in Stockholm County Council. The average stay in hospitals has
substantially reduced from 10 days to 4 days, and there has been a shift towards homecare. Although Sweden
has the oldest population in comparison with EU 15, Norway and the USA; it also has the highest life
1
expectancy of a baby boy born in 2005 (Source: OECD, 2007) . It also has good accessibility, in relation to
number of treatment centres in proportion to population size (although there are long waiting times in
elective care). Sweden has very good outcomes in terms of lowest infant mortality rate, “avoidable death” and
“too early death”, and low mortality from cancer. It also has high medical quality with a low percentage of
infections. The number of beds per 1000 citizens is the lowest for Sweden and the highest for Germany.
Following the presentation, there was a discussion around decision-making structures. In Sweden, quality
standards and standardisation are the responsibility of the individual councils who have a high degree of self
governance. According to Göran Stiernstadt there were no specific standards for room sizes; design is guided
by building and construction industry regulations. The importance of reorganisation was also described to aid
the Swedish health service to reach a higher degree of effectiveness. For Göran Stiernstadt one possible
criticism of the decentralisation process was that 21 county councils provide hospital services for a small
population (9 million). Although there are a number of statistics available for the county council-provided
healthcare services, Göran Stiernstadt believed that there are few studies for municipal and local systems. This
can prove to be a hindrance when evaluating services such as stroke care, where only 20% of patients are
treated by county councils and the remainder are treated by municipalities. There were discussions around
accessibility issues within UK and Sweden; the UK health system is often criticised for postcode availability of
treatment. In practice this is also the case in Sweden, with accessibility differing regionally. Access is a problem
across all health systems.
1
OECD, (2007) Health at a Glance, OECD indicators, (editor’s reference).
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2. Tools and Methodologies for
Planning – parallel sessions A and B
2.1. The New Karolinska Solna University Hospital – The New Centre for
Integrated Specialised Care, Research and Education
Professor Lennart Persson, Managing Director of the New Karolinska Solina Hospital.
This presentation outlined the principles of the new Karolinska Solna University Hospital design that had been
commissioned by Stockholm County Council. For Lennart Perssson the mission for the design was to provide a
world class and high quality facility for healthcare, research and education. The new hospital would act as the
central hub of a competitive health care system, a specialised tertiary care hospital for the region and would
play a central role in the development of Stockholm as a leading life science cluster. Principally, the design was
said to put the patient perspective first, to achieve patient integrity, patient safety and better comfort.
According to Lennart Persson there was a strong political drive and strong County Council leadership between
2001 and 2010 which drove the decision for a new hospital. The site was as large as a new town and it was
spread out over some 40 buildings, with weak connections and logistics. There were several old facilities,
which were unsuitable for future healthcare, and a number of buildings that were expensive to refurbish.
Historically, patients used to be seen by one doctor only; however today healthcare delivery is often multidisciplinary with many specialists involved in patient treatment. Forming these teams across buildings was
difficult. The ambition was that this building project would be a catalyst for a change in healthcare and not just
a building; however, this was perceived as very difficult to achieve. The product structure for the NKS project is
described below (Figure 7).
Figure 7. NKS Project Structure
The details of the scheme are:
Gross total area: Max. 335 000 sq.m.
Cost: Max. € 1.3 bn.
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Single rooms for all in-patients
180 ambulatory rooms
Clinical laboratories
Clinical research laboratories
Teaching facilities
600 beds (125 ICU/high dependency care & 75 postop.)
100 day-care beds
100 rooms at adjacent patient-hotel
The principle of the approach to designing the hospital was:
Construction or building
Activities and medical content
Thematic organisation
The NKS themes that were used to organise the building are shown in Figure 8. These include: Children,
Cancer, Heart, Inflammation, Neurology, Restorative Medicine, Immunology, Image and Function,
Proteomics/Genomics, Laboratories.
Figure 8. NKS Building Organisation Themes
The key was organisation around the patient, rather than the specialist. Other important elements were
development of clinical pathways and logistics, and separation of acute and elective patient streams. The site
has been designed around clusters of:
1. Research and education
2. Clinical spaces
3. Hotel areas
Historically Stockholm Karolinska transferred burns, stroke and children to other hospitals outside the region.
The building has been designed around a thematic organisation as shown in Figure 9, rather than around
specialists.
Mott
Neurology,
Cardiovascular
Systems
Inflammation,
Restorative
Medicine
Children
Cancer
Extracorporeal membrane
oxygenation
General Intensive Care
Cardio-Vascular
Neuro-Intensive
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Stockholm, May 5-7, 2010
Figure 9. Zoned Building Elevation Layers
Elective and acute patient streams are separated as shown in Figure 10.
Acute / Emergency
Elective
Figure 10. Separation of Elective and Acute Patient Streams
Acute care is operated 24/7, 365 days of the year. Therefore there was a need to concentrate “the Night
Hospital” as shown in Figure 11.
Day
Night
Figure 11. Separation of the Night and Day Hospital
The building has also been designed around transport pathways for the staff and in bed transportation for
patients. Specific transportation routes have been designed for trauma, stroke, acute heart and extracorporeal
membrane oxygenation (ECMO) from acute emergency entrances and between Intensive Care and other
diagnostic and imaging suits (such as X-ray). These routes are considerably different from those on the
previous site that sometimes required patients to be transported 1.5 km from A&E. The design also
incorporates flexibility in the positioning of the ground floor equipment and heavy technologies. With regards
to departmental adjacencies, Neuro or Intensive Care and Cardio were designed to be close to Imaging.
Trauma was organised for patient arrival by ambulance and air. An important distinction was made between
wet and dry labs, because hygiene and cleaning are different for these. Within wet areas this can be 2 hourly
cleaning, while for dry areas this can be 2 weekly. Research was carried out on the movement of staff by
Chalmers University.
2.2. Master Planning in the 21st Century: NKS, Huddinge and Södertälje
Hospital
Agneta Philipson, Architect and Property Developer, Locum AB.
This presentation concerned Locum’s Property Development Plan (PDP), and it addressed the questions: how
can long term sustainable development in hospital facilities be achieved within the Stockholm County Council
area, and what tools are available? It provided two case study examples: Karolinska University Hospital in
Huddinge (the largest hospital managed by Locum) and Södertälje hospital - one of the smaller emergency
care hospitals under Locum’s care.
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Property Development Plans (PDP) are a means to achieve long-term overall strategy for the continued
development of the hospital complex, guidelines for future changes and analysis of the possibilities and
limitations of the hospital property. As such they should incorporate:
Adaptability – ability to change layout, function and volume overtime - based on healthcare needs.
Long-term effective structure – a structure with optimal conditions for communications, flows and
functions.
Efficient premises – premises that support and streamline care pathways.
Design – strengthen the image of the hospital as a Medical Science Centre with specialised health care and
integrated research and education.
In order to achieve this it was necessary to take a long-term approach (because of the lifespan of the buildings
and infrastructure), a holistic approach (to not limit opportunities for other parts to grow), an efficient and
general approach (to adapt to constantly changing needs) and a participative approach (to build understanding
and embedding).
In a study of Södertälje Hospital in 2009 property analysis was used to understand the existing infrastructure in
terms of its long-term suitability for healthcare. It looked at standards, technical infrastructure, adaptability to
apply modern standards and a number of other factors. The outcome of the analysis was that only few
buildings were suitable for emergency care, and they were in need of major investment (Figure 12). The results
of the analysis further showed that there was a need for a high proportion of new construction, and some
buildings would be suitable for long-term care once renovated. There was a need to leave or sell a number of
unsuitable properties for other purposes. As part of this work, schematic principles, general activities and best
working practices were established for wards and outpatient facilities and used to assess existing spaces for
their change of potential use. In the following Preliminary Study for Södertälje Hospital a “Null Alternative”
was also studied which only included the equipment and remodelling measures needed to achieve a
somewhat functional condition. The result of that study showed that the “Null alternative’s” ‘patch and repair’
strategy does meet certain short-term needs, but is not a long-term strategic alternative
Green indicates the
building is long-term
suitable for this type of
care
Yellow indicates 2–3
characteristics are
lacking with regard to
long-term suitability.
Risk of in-vain
investment
Red indicates the
building doesn’t offer
long-term suitability for
any kind of healthcare
Figure 12. Property Development Traffic Light Plan
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Stockholm, May 5-7, 2010
The Karolinska University Hospital at Huddinge is the largest hospital Locum manages and is also the other half
of the New Karolinska University Hospital in Solna – the future New Karolinska, NKS. In the ongoing Property
Development Plan for Karolinska Huddinge (424,000 m2, 800 beds and 750,000 outpatients each year) the
main goal is to try and reconcile different needs and interest in a long-term solution for the next 20-30 years.
With an estimated population increase of 1-2% per year in the whole Stockholm area the need for new
hospital beds could rise to roughly 800 beds in a maximum scenario for the Huddinge site. The PDP for
Karolinska at Huddinge tries to ensure that the hospital’s existent functional structure can be strengthened
and developed. Due to the size and number of University Hospital buildings it is vital that there is good
communications and separated flows for patients, beds and goods. The PDP goal is a sustainable hospital
structure with a high degree of standardisation and generality with premises that support streamlined and
cost-effective healthcare. During the next decade, the hospital structure should offer premises where
outpatient care can be located on the periphery of the hospital to enable easy access for patients and
integration with other services, research and private enterprises. The Property Development Plan for
Karolinska Huddinge aims at providing a comprehensive standardised and adaptable structure that will be easy
to modify for different needs and scenarios.
2.3.
The Concept Program
Anders Lövefors, Architect and Property Developer, Locum AB.
Stockholm County Council and Locum are facing the challenge of developing buildings for emergency care
units and operational suites for 3 different hospital sites. The Concept program is a tool used to plan these
projects in order to make them successful. This program has been produced in collaboration with
representatives from healthcare services and the New Karolinska Solna University Hospital. The key goals of
the Concept Program are to develop buildings that:
support healthcare processes and new logistics solutions
improve patient security and privacy
enhance working environment for staff
have high architectural value
Sustainable concepts have been created for acute care, maternity, surgical, sterilisation and imaging processes
areas. Based on these areas, a shell and core building has been created which includes general requirements
concerning design, functionality and long term strategies. The Concept Program focuses on standardisation of
processes, solutions and supporting functions. In order to deliver safer and more efficient healthcare, buildings
require a high level of internal flexibility, activities to run and minimal disruption along with good linkage
between activities. The following diagram (Figure 13) depicts the lifespan concept in which various parts of the
building are divided according to the life cycle of individual elements. The longest lifespan of over 100 years is
linked to the community; for example, access roads. Other elements with long lifespan, which also impose
restrictions on the building, include facades, load bearing frames, lifts, stairs, and shafts. The third element of
the building is that which is linked to activities with the shortest lifespan; for example, partition walls,
suspended ceilings, installations and equipment. The Concept Program for shell and core building focuses on
the elements with a longer lifespan.
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Figure 13. Lifespan Concept (Derived from illustration from White architects)
Buildings have to adapt to changing activities. There are two main schools of thought concerning healthcare
facility building programmes:
Let the prevailing demands of activities dictate the dimensions of the building.
Aim for general properties that will allow space for unknown future technical or functional requirements.
From past experience, it can be seen that, over time, a series of disruptive conversions will take place in a
healthcare building, and the need for a new building often arises before the old one is written off.
Furthermore, when some activities are forced to move the linkage to other parts of the hospital is broken.
Throughout this period (can be decades) the functionality is decreased. The Concept Programme is in part an
attempt to mitigate these disruptions, by careful consideration of:
General goals
General design of building
Design of frame and choice of module
Design of installations
Conversion
Adaptation to existing conditions
Engineering standards for construction building
Installation
An example of these general properties is that the strategy for future conversion is included in the initial
planning phase. Conversion issues inside and around the building, including conversion scenarios for
converting the whole building or parts of it, planning for lifting of heavy medical equipment, and minimisation
of disruptive effects of a conversion on adjacent buildings, are included in the strategy.
Figure 14 depicts the interpretation of the concept program. The requirements can be solved in alternative
ways in new builds relative to those illustrated in the concept program. In concrete construction project, it is
easier to see what solutions are best compared to the price, performance and risk.
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Figure 14. Concept Programme
The Concept Programme has been applied at the Södersjukhuset hospital, where it has contributed to a
proposal that more likely will deliver efficient healthcare, with increased customer benefit and lower costs for
the property owners.
2.4. One New Hospital per Decade: Is there a Swedish Way? A History of
Planning Health Facilities
Anna Montgomery, White Architects, Sweden
This presentation described the Swedish tradition of standardisation approaches and provided examples of
master plans from Sweden. The speaker also provided a brief background to White Architects, who are one of
Scandinavia’s leading architectural firms with 500 employees in Sweden and Denmark. 15-20% of their market
share has always been in healthcare projects. Their expertise includes urban planning, landscaping, interiorand product design, project and environmental management and restoration. Anna Montgomery further
explained the knowledge building exercises that function as a very active platform to explore innovative ideas
sometimes in-house but more often with clients and users. They are currently engaged with Forum for
Healthcare Building Research (Chalmers), Swecare, UIA-PHG (International Union of Architects - Public Health
Group), and Sustainable Hospitals.
She also discussed the standardisation approaches in Sweden along with the social model responsible for it.
SPRI were the older standards that were based on centralisation and decision making. These standards dealt
with technical issues, disposition and details of room modules etc. In 1990, the decision making was
decentralised to the county councils and SPRI was not adopted anymore. A new project ‘konceptprogram’ has
been set up in Stockholm county council to revive some ideals from the 70’s and resume a standardisation
approach. She provided the following examples of Master Plans in Sweden.
By way of an example the University Hospital of Umea Master Plan combines research and education,
healthcare and areas for development. The following Master Plan (Figure 15) depicts the relation to the
surroundings, entrances and areas for development (light green squares). The main healthcare buildings are
retained within this project. New buildings under construction include departments for paediatric, women’s
and children’s care and cancer treatment and neonatal care.
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Figure 15.University Hospital of Umea Master Plan
In the following Uppsala University Hospital Master Plan (Figure 16) the light yellow parts depict areas of
continuous improvements and dark yellow for areas of new buildings. The main logistics and flows are
retained within the plan. A new psychiatry block is under construction, designed by Tengbom architects.
Figure 16. Uppsala University Hospital
In this Linkoping University Hospital Master Plan they identified four levels of durability (Figure 17). These
included: demolition as soon as possible to utilisation of buildings for at least 20 years with continuous
improvement.
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Figure 17. University Hospital in Linkoping Master Plan
Examples of Southern Alvsborg hospital, Sahlgrenska University hospital and Skane University Hospital were
also provided.
Sweden has gone through a 20 year period of healthcare decentralisation. As such responsibility for
construction has been at a county level and many counties have focused on maintaining existing estates, few
have been engaged in new department or block building but there have been no significant new build projects
other than Karolinska. Over this period however many counties have been developing master plans, many of
which are now seeking approval. At this stage there is a huge need for new investment and a new generation
of hospitals and period of extensive reconstruction is likely. However there is no national institution or
department that can oversee and regulate such a large scale structural change. This possibility for upcoming
practical end economical problem highlights the need for coordination and the need for a centralised
regulatory or building commissioning authority. The importance of research networks and knowledge
mangement in order to develop new lean healthcare and better decision making was seen as vital in moving
forward.
2.5. Decision Support for Hospital Reconfiguration: New Guidelines and
Tools
Marte Lauvsnes, Senior Health Advisor, SINTEF Health Research, Norway
This presentation described the challenges for hospital planning in Norway along with the tools and guidelines
currently used within hospital planning. At present, in Norway there are very few big hospital projects
(Akershus University Hospital, St Olav’s Hospital, Rikshospitalet University Hospital, New Østfold hospital). The
current planning process tends to focus on building projects. However, there has been a growing need to look
at “everyday hospitals” i.e. old hospitals that require refurbishment and reconstruction. She described this as
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“continuous processes” which take place within the built environment and require continuous planning for
minor add-ons in projects and for changes in healthcare delivery between various specialities.
New technology and medical developments, changes in inpatient, outpatient activities, introduction of new
regulations (food delivery, infections, and carbon emission reduction), workforce and political demands are all
drivers for changes in healthcare systems. Building adaptability has to meet the challenges set by activity
demands, and the key issue is to determine construction changes to meet these demands. It is imperative to
think about a strategy to deal with this change. Traditionally, there have been systematic guidelines for the upfront planning process, which deals with strategic, conceptual and design phases along with decision making.
These have been developed by the Competence Network for Hospital Planning and adopted by all regional
health authorities. There are guidelines for master plan development and cost calculation but there is a lack of
thinking about the “continuous processes”. There is a need to develop and change this guidance for smaller
projects.
There are a number of tools for activity and capacity analysis:
Space classification system- to measure space capacity, productivity and utilisation; and for comparison
between units and hospitals
Care pathway tool- taking account of future capacity and space demands; extrapolating activity,
calculating and mapping capacity and space
Flow diagrams and illustrations
All existing hospitals in Norway are classified through the same space classification system which compares
space utilisation and productivity and is developed by the Competence Network for Hospital planning. They
have been working with a care pathway model (described by patient processes) within a trust that is
undergoing reconfiguration to see how activity and capacity can change needs. It is also trying to answer
questions: how should flexibility be incorporated within a new building to manage change? How to reconfigure
an old hospital within a new hospital?
Basis Model for calculating and dimensioning a hospital (based on area and space standards) is shown below
(See Figure 18).
Figure 18. Hospital Dimensioning Calculation
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Care pathways are determined based on activity and capacity calculations. So far the trend has been for
vertical thinking but this has changed to horizontal thinking. The speaker further provided a brief
demonstration of the tool. Furthermore, she described an innovation project financed by Innovation Norway
and the Health Directorate for mapping demands for planning methods and tools for reconfiguration of
hospitals. This project aims to connect existing everyday planning tools to enhance the decision process
through visualisation (of alternative solutions) and communication (between various stakeholders).
2.6. Innovation in Healthcare Infrastructure Planning in Italian Regions –
Tools and Methods
Dr Gianluca Ghiselli, Asti Azienda Sanitaria Locale, Asti, Italy
Dr Gianluca Ghiselli provided a background to the Italian healthcare system, in which primary care is
traditionally available from 08.00 – 20.00 during the week, with no cover over the weekend. He further
presented a case study of Cardinal Massaia Hospital, a middle sized Italian hospital in Asti which has a density
of 144/km2. The hospital has about 600 beds and the emergency room receives around 61,000 patients per
year. This hospital has a central square dedicated to non-hospital activity and has proved to be a useful
connection between hospital and the town (Figure 19). It also has a range of additional specialities, which
patients can visit without prior booking. He further explained the concept of health houses, where GPs work
with hospital’s specialist and patients have access to laboratory tests (including X-rays), in other words the
hospital move to the people instead of the other way round. He also introduced the Project, Economy and
Health (P.E.H.) programme which started in 2008 and targets to prevent diseases and provide healthier living
through lesser health facilities. He expressed the need for healthcare facility to catalyse some social and
economic aspects with a large impact locally with possible improvement in health and economy. The three
steps of development in this programme include:
Start “2Q” programme (Daily Quality, Qualità Quotidiana in Italian): The main objective is to develop
short supply chain by using local fresh food. This enables to stimulate local economy along with
improvement of environmental conditions due to less use of transport and shorter journey times. This
has further reduced the consumption of frozen food within the hospital.
Weak people rehabilitation (drugs and alcohol patients): This short supply chain was utilised to
introduce rehabilitation patients to a work environment (production of jams, taking care of animals
etc). This worked as social therapy for the patients. A dedicated area was identified in front of Asti
Hospital for this purpose.
Optimise energy consumption in Asti Hospital and all medical facilities: This step is an essential part of
an E.C. project called “Europa 2020” dedicated to facilitate renewable energy, energy saving and
reduction in polluting substances.
Since June 2007 this hospital has also signed an agreement with the Regional Government for ‘Research in
Innovative and Renewable energy sources’. This was initiated by the introduction of a hydrogen continuity
power supply dedicated to an emergency room. Other means included:
Energy saving by means of biomass (wood) co‐power supply installation and modification on
refrigerant system
Connection of the two hospital’s buildings to the above mentioned co‐power
As part of optimising the energy consumption in Asti Hospital renewable fuel became part of the ‘short supply
chain’ as sunflowers (or short rotation forestry), rape or wood waste (bio-oil) or biogas from anaerobic
fermentation of kitchen waste. A number of other projects are also being developed, such as:
Photovoltaic electric installation
Solar cell heating system
Hydrogen UPS (as for the Emergency Room)
Heat pump as heating system
Refrigerant system improvement
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Geothermal energy
He concluded by summing up the advantages of short supply food and energy chain. This has helped in
reduction of hospitals heat costs. They plan to implement these measures in other hospitals; such as Valle
Belbo. He further demonstrated how a hospital can work as a catalyser to promote economic and social
activity through events such as debates, art exhibitions, and school meets.
Figure 19. Cardinal Massaia Hospital, Central Square and Relationship to Town
2.7. French Regional Planning: To Build New Hospitals or to Renovate
Existing Structures?
Bertrand Bailleul, President, Forum European; CEO, Hospital Saint Jean des Gresillions, Paris, France.
This presentation addressed the link between standards and funding and provided some examples of how
these considerations have played out in practical case studies. It also detailed how economic drivers have
driven development.
Over the past 10 years France has seen a regular succession of public sector healthcare reforms that have
contributed to rapidly changing strategies. In 2002 there was an ambitious investment policy (16 billion Euros)
in infrastructure. This paid for 900 projects that renovated or rebuilt some of the 3,000 existing hospitals. The
result of this policy was 156 new and refurbished hospitals with improved buildings and introduced new
technologies. The procurement of new buildings started quickly and the evaluation of the viability of schemes
was not as effective as it could be, with the result that some hospitals which already had problems went
further into deficit. Evaluation was also problematic as all schemes started at different times. There was a
subsequent programme for investment in technological infrastructure. This policy was for 20 billion Euros.
Those healthcare providers that were successful were those who could demonstrate that they had been
working together to integrate. A number of examples were discussed along with some of the political drivers
that enabled them to obtain funding. Local decisions were made against five key criteria. These included:
Hospital capacity
Need for re-organisation and the bringing departments together
Architectural improvement
Failure to comply with new regulations (e.g. fire and water)
High maintenance costs and difficult to maintain systems
Political decisions were made on three other criteria, these included:
Care priority areas (e.g. reduced cost care pathways, safety)
Affordability (borrowing capacity, capitalisation, credit rating)
Political quality (how does the work being carried out help to deliver the aims of the political system?)
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2.8. Clinical Space Calculator: How to Move towards Generic Healthcare
Spaces and Fit the Facilities to the Activity
Jonathan Millman, Department of Health, Gateway Reviews Estates & Facilities Division, England; Ashley
Clough, Parallel Interactive, England
This presentation previewed a new Department of Health (DH) approach for defining the utilisation and
capacity needs of new spaces. The objectives of this new tool are to:
Link baseline space recommendations to the cost of a facility and the activity that it generates;
demonstrating the relationship between the cost of a building and the income it generates
Establishing opportunities for providers of care to drive down costs
Identifying generic rooms, across specialities, that can be used flexibly and adapt to change
The future intended direction is to:
Achieve better value through encouraging the use of rooms on a time-separated basis for a range of
different activities and the elimination of under-used facilities
Relate them to the ongoing development of Healthcare Premises Cost Guides (HPCGs) based on UKindustry best practice
Link space to activity calculations and to graphic room data sheets
The new DH approach to costing will differentiate between public, clinical and staff spaces. Each space within
the new example schedules of accommodation is categorised according to its location (or zone) in the
department. The three space types correspond to three zones, which are defined as follows:
Public zone: The zone within the department that contains the reception and waiting area and is
accessible to the public.
Clinical zone: The zone from which the delivery of the departmental function occurs. Most patient/client
contact spaces will be located here, as will any clinical and staff support spaces required in the immediate
vicinity.
Staff zone: This zone contains staff support spaces.
The new schedules of accommodation include allowances for engineering, circulation and communication
space. Each allowance is expressed as a percentage of the net internal area and when added to the net
internal area produces the gross internal area (GIA).
The presentation included a demonstration of the new tool. This allows healthcare planners to determine the
capacity and number of rooms within a facility using a number of demand calculating parameters. These
include demand calculated against a population / list size / default catchment. Capacity and room numbers are
calculated according to whether spaces are designated or shared and their level of utilisation. Then basic
occupancy assumptions are added to include: weeks per year, opening hours, number of sessions per day and
average length of patient appointment (which can be changed and used to play out what-if scenarios). The
existing prototype tool is being trialled using only primary care and maternity data at present. Services have
pre-defined generic room types and typical annual access rates. The discussion after the presentation
identified a similarity between this approach and work being carried out by SINTEF in Norway. The question of
how the system calculates other support spaces as they relate to clinical areas was raised as well as the need
to better demonstrate efficiency and effectiveness (that is, the savings that can come from increased
utilisation or through the use of shared spaces) along with rigorous testing and local validation of a number of
underlying assumptions. There is also a need to explore how the tool could respond to changing clinical
technologies.
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3. From Planning to Realisation: how to
get ‘there’ from ‘here’
3.1. The Ex-Ante Evaluation Methodology in Regional Planning: The
Italian Case
Dr. Simona Ganassi Agger, Ing. Daniela Pedrini – Societá Italiana dell’Architettura e dell’Ingegneria per la
Sanita(SIAIS)
This presentation provided a background to the Italian health system along with the state of health
infrastructure and public investment in general. The main challenges for the Italian health system include
getting regional health systems to deliver equal quality services in all regions, in order to reduce the gap
between north and south of the country. There is a growing need to develop national and regional networks
based on highly specialised hospitals. Out of 918 hospitals, 16% are more than a century old, 43% were
constructed before World War 2, and only 17% of the hospitals are less than 30 years old. There is a need to
invest in infrastructure and to plan local social care and health services based on a high level of home-based
care.
The methodology for ex-ante evaluation of regional investment programs has been called MEXA (Methodology
of Ex Ante Evaluation), an interactive tool which enables an iterative process of evaluation and also provides
guidance (Figure: 20) to the regions in preparing programme documents. MEXA comprises of:
An explanatory summary
A Socio-Medical Economic Analysis, consisting of epidemiological, demographic, and social-economic
analysis to identify and quantify the need for health services
A Strategy proposed to meet the identified needs
Coherence of strategy with EU, national and regional policies
Expected results (based on a system of indicators) and impact evaluation (social, program value and
technology assessment)
Procedures to plan implementations (management structure and quality of public private partnership,
whole life cycle investments) and financial plan, construction and procedural monitoring
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Figure 20. Methodology for Ex-ante Evaluation of Regional Investment
From 2004 to 2008 this methodology was tested in the regions of Abruzzo, Puglia, Calabria and Sardegna,
where health infrastructure programs had not been developed. It proved to be useful not only for evaluating
plans before implementation but also as a planning tool. Recently ‘Payback Plans’ for the health sector
spending have been introduced which are aimed towards economic and financial equilibrium at regional as
well as national level. Regions which suffer from a significant health sector deficit have to investigate their
most problematic issues and the present their payback plans. MEXA has proved, during the period of its
application, to have significant value as it provides a common tool for structured investment planning in a
system of healthcare based on regional decentralisation. In future its effectiveness will have to be measured
against its ability to evolve with changing health needs within society. The presentation concluded with some
brief case studies of new innovative hospitals which included: the Meyer Children’s Hospital in Florence; the
Verona University Hospital of Borgo Trento (new surgery complex); the Asti Provincial Hospital (developing its
“piazza”); Mestre Venice (the “terraferma” new hospital); and Modena Baggiovara (the hospital structure that
represents one of the regional “hubs”).
3.2.
The Hospital and its Role in Economic Development
Alan Hennessy, Architecte-associé Président, bdpgroupe6
This presentation began with a brief introduction to bdpgroupe6, who offer comprehensive professional
services for the built environment. Bdpgroupe6 currently designs 2% of all UK’s new non-residential buildings
and are working on 55 hospital sites in France. They also have international projects in over 25 overseas
countries and have won over 330 awards. Alan Hennessy further explained the economic impact of hospitals
with the help of certain examples; the population of Stockholm is 760,000 (city) and 1,800,00 (county) and the
active population constitute 66% of this. Healthcare or social care employs 13% of this active population, only
wholesale/transport and financial services employ more people. According to Business Week (Sept. 2006)
since 2001 in the US, the healthcare industry has added 1.7 million jobs and is an important element in
economic growth, see table below (source: Business Week, 2006).
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Sector (In the US)
Healthcare and
related industries
Construction and real
estate-related
Government except
hospitals
All other Private Sector
Million jobs created
2001-2006
1.7
0.94
0.9
1.2
According to the US Census office (2009) the healthcare industry represented 12% of total US workforce in
2006. The healthcare industry consists of companies that are developing and manufacturing drugs, medical
supplies, health insurance providers; wholesalers and retailers, health charities and hospitals. The healthcare
sector and its employees purchase large amount of goods and services from local businesses. This in turn
provides a benefit to the economy and this secondary impact is referred to as the multiplier effect (expressed
in employment and economic terms). He further explained the concept with the following example:
employment multiplier of 2 indicates that if one job is created by an industry one additional job is created in
other sectors due to indirect and induced spending. The other contributor to the multiplier effect is the
income, as this sector is labour intensive most of the spending ends up with the workers and this income is
then spent locally, contributing to the local economy. The multiplier effect is calculated by considering both
these factors. He also presented a comparative analysis of the economic contribution to GSP through
healthcare in 2009 for Missouri ($36,7 bn), Iowa ($14 bn) and New Hampshire ($3,7 bn). The healthcare
industry also creates other job opportunities apart from related employment. Some economists predict that
medical spending may rise to 25% of GDP by 2030. US healthcare’s share of jobs could rise to 15-16% of the
labour market from the current 12%. It is important to strike a balance with job creation and provide a well
balanced economy.
In the example of Clermont Ferrand University Hospital, the primary objective was to draw up development
guidelines for Clermont Ferrand’s extensive unused industrial land and to provide adequate access to public
transport. Bdpgroupe6 produced a spatial development plan to respond to the social, economic, transport and
environmental needs and the development was concentrated around an 800m future tramway line. The
economic contribution by extrapolation for this hospital is 5.6% of employment in Clermont Ferrand
(population 144,000). This may create 3000 jobs in the future (2010-2020).
3.3. The North Tees Momentum Project: Care Pathway Planning and the
Consequences for the Health Estate
Carole Langrick, Deputy Chief Executive/Director of Strategic Development, North Tees and Hartlepool NHS
Foundation Trust; Alison Wilson, Director of Health Systems Development, NHS Stockton.
This presentation concerned the exploration and integration of new care pathways with primary and
community and acute hospital capital projects. The health status of the population of north Tees is particularly
challenging, and long-standing political issues have made it difficult to achieve efficient re-organisation of local
health services. The project had managed to go a long way towards a successful outcome because of a highly
collaborative programme jointly led by a Foundation Trust and local Primary Care Trusts. This had enabled
whole system change, service redesign and care pathway change in anticipation of substantial capital
development (Figure 21).
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Figure 21. Whole System Change Framework
The Project has proposed a mixed economy of funding – LIFT and Public Dividend Capital and at the time
would have been the first scheme of this type to be funded out of Public Dividend Capital for at least 15 years.
There were a number of drivers for change, including past experience (past service reviews), the strength of
existing strategic planning and partnerships, alignment with the national policy direction, attention to safety
and quality, a high aspiration for service improvement, the high priority placed on improving the health and
wellbeing of the population and the need for sustainability in service provision. The difficulty in achieving a
solution that was acceptable to all parties led to a review by an Independent Reconfiguration Panel (IRP). The
IRP made a number of recommendations, which included the need for a: modern new hospital to replace the
existing out of date buildings, provided on a new site in a well situated location accessible to the people of
Hartlepool, Stockton, Easington and Sedgefield. It also recommended further initiatives to improve the
provision of primary and community care, including community midwifery. A community based model was
determined, as shown in Figure 22.
Figure 22. Community Based Model
One key lesson from the Momentum project is the need to align all future service models with the design and
build of facilities. Furthermore, the need to undertake major service change clearly requires a sharp focus on
change management, a strong emphasis on the financial model and the need to engage people along the way.
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3.4. Integrated Infrastructure Planning in UK and Sweden: Two
Perspectives on the Context and Tools for Strategic Development
Grant Mills, HaCIRIC, Loughborough University. Phil Astley, Medical Architectural Research Unit, UK. Göran
Lindahl, Chalmers University of Technology.
This presentation compared the organisational or project structures, standards and tools, master planning
approaches and ongoing research of Sweden and the United Kingdom.
The findings of the comparison of the organisational structure of both countries was that England has an array
of estates and facilities project and procurement structures and varying facilities management roles versus
those like Locum in Sweden. Broadly speaking the organisational levels were similar; however there seemed to
be a difference in the way the two countries re-organised; with Sweden seeing this as an internal business
process, whereas in England it might be more politically driven. With regards to standards, guidance and tools;
England was seen to have a more centralised approach and relying more on standards. Sweden is seeing the
need for greater coordination and has a number of advanced stakeholder participation approaches developing
solutions rather than basing them on standards. Both countries may be able to learn from the other taking
health care context and societal and political structure into account. A comparison between the master
planning approaches used in Sweden versus those used in England was made. Sweden appeared to have a
more well defined approach to master planning, which included the long term involvement of a lead architect,
a high level of urban planning, the use of design competitions and shared learning (in place of guidance). Three
types of infrastructure (care, estates and transport) were described along with a new research project that is
investigating the integration of these. See Figure 23.
Figure 23. Integrated Healthcare Infrastructure
This work also explored the need to understand care model scenarios against each care pathway, as shown in
Figure 24.
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Figure 24. Urology Example Care Model Hierachy of Infrastructure
The master planning approaches taken towards acute and primary care were compared using three example
projects: Örebro, Cambridge and Finchley Memorial Hospital. This demonstrated the importance and the need
for an understanding of scenarios that can change over various timescales.
Recommendations were made for: clearer estates and facilities competencies, a definition of the role quality
standards play versus locally defined stakeholder engagement, the need for open scenario planning
approaches that facilitate the discussion of scale and distribution and an integrated European approach to
research and development.
3.5. Bringing Capital into the Equation: Building a Health System where
Capital Goes with the Diagnosis
Rhonda Kerr, Rhonda Kerr and Associates, Australia.
In the Australian healthcare system capital for healthcare has traditionally been assessed with reference to
institutions and their requirements to provide a range of services for patient treatment and care. Expenditure
for capital in healthcare has been set separately from recurrent expenditure and, after the initial investment,
has been seen as a free component of healthcare delivery, until repairs or maintenance or replacement was
required. Healthcare facilities are largely seen as assets with very long life spans. Reforms in hospital service
funding proposed are for the capital to be attached to individual patient funding based on diagnosis groups.
Capital along with labour and consumables is one of the significant inputs to healthcare yet has been
undervalued as a driver of major change and tool for reform. Traditionally budgets for capital have been
determined by the fiscal conditions at the time. This approach has become increasingly problematic and has
2
impacted on the efficiency and effectiveness of the health service delivery system . The competition for capital
2
Garling Report, (2008) Final Report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, Commissioner
Peter Garling SC. Available at: http://healthactionplan.nsw.gov.au/garling-report.php.
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disenfranchised less attractive services such as mental health, aged care, rehabilitation services and sub-acute
care. The overall connectedness of ICU, theatres and emergency departments to acute beds and outpatients
services were also lost in this process leading to blockages and imbalances. Oddly, healthcare capital
investment is not been seen as a driver for higher productivity, unlike private industry which prioritises capital
investment on a Return on Investment (ROI) basis.
3
The National Health and Hospitals Review Commission lead by Dr Christine Bennett after nearly two years of
consultation, found the case for health reform was compelling, that the system was too fragmented and that
there were issues with respect to access and health outcomes. The Review set a blue-print for creating an agile
and self improving health system with long term financial sustainability. A key element of the reform package
was funding hospital services, including outpatient and emergency department services, by diagnosis related
group or activity based funding. For the first time this funding will include a realistic cost for capital per patient
episode. Capital is usually defined as buildings and major equipment but now needs to also include
information management systems.
4
Healthcare in Australia costs close to $125 billion US dollars per annum, and employs 7.3% of the workforce .
The average Australians life expectancy is high at 81 years and most health outcomes are in the higher levels
5
when compared internationally . However aboriginal populations have lower than average life expectancy,
higher infant mortality, significant chronic disease, higher trauma rates and poorer health outcomes. All
6
Australians have access to the 768 free public hospitals which treat 4.7 million patients per annum . Last
financial year it was estimated that AUS $53 billion was invested in capital for healthcare, or 5.6% of all health
expenditure. Federal and state governments fund nearly 70% of all health expenditure, individuals pay for 17%
7
and the remainder is funded through insurance . One of the primary objectives of health reform in Australia
has been to keep healthcare costs below 10% of GDP, and to minimise financial burdens on the individuals and
8
9
government as the population ages. The NH&HRC Review and the Productivity Commission Research Report
have both sought to create a new funding system for sustainable healthcare. Finding the right capital price is a
part of the process. The Productivity Commission has two options for capital cost by DRG. The first is the user
10
11
cost of capital and the second is based on a multivariate analysis .
However, there is a need for capital and life cycle costs and costs that are allocated around the patient, rather
than the cost of existing capital replacement. Appropriately priced DRGs integrate hotel services, circulation,
3
Commonwealth of Australia, (2009) A Healthier Future for all Australians- Final Report of the National Health and Hospitals Reform
Commission, Canberra, pg 47.
4
Australian Institute of Health and Welfare, (2008) Australia’s Health, AIHW, Canberra, pg 433ff. Available at:
http://www.aihw.gov.au/publications/index.cfm/title/10585.
5
Commonwealth of Australia, (2009) A Healthier Future for all Australians- Final Report of the National Health and Hospitals Reform
Commission, Canberra, pg 47.
6
Productivity Commission, (2009) Public and Private Hospitals, Research Report, Commonwealth of Australia, Canberra, Overview pg xxv.
Available at: http://www.pc.gov.au/projects/study/hospitals/report.
7
Australian Institute of Health and Welfare, (2008) Australia’s Health, AIHW, Canberra, pg 400. Available at:
http://www.aihw.gov.au/publications/index.cfm/title/10585.
8
A Healthier Future for all Australians, (2009) Final Report of the National Health and Hospitals Reform Commission, Commonwealth of
Australia, Canberra.
9
Productivity Commission, (2009) Public and Private Hospitals, Research Report, Commonwealth of Australia, Canberra, Overview pg xxv.
Available at: http://www.pc.gov.au/projects/study/hospitals/report.
10
Productivity Commission, (2009) Public and Private Hospitals, Research Report, Commonwealth of Australia, Canberra, Overview pg 300.
Available at: http://www.pc.gov.au/projects/study/hospitals/report.
11
Productivity Commission, (2010) Public and Private Hospitals: Multivariate Analysis, Supplement to Research Report. Available at:
http://www.pc.gov.au/projects/study/hospitals/supplement.
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diagnostic and administrative functions as well as teaching and research. It is expected that costs for capital
will be calculated for the full range of capital used by the patients for the treatment regime including wards,
outpatients’ areas and theatre and imaging suits. DRG payments also include clinical costs, imaging, theatres,
pathology, pharmacy, ICU and hotel costs within a hospital. Allocating costs around the patient better ensures
that capacity matches demand and accelerates the process of improvement. When capital travels with the
patient the system has a conduit for change. Capital can be transforming when it is allocated as a payment.
When Capital is calculated using best practice benchmarks it is possible to flag appropriate investment
responses to subtle variations in practice. The capital link to best practice and admitted patients then builds
the case for future investment patterns at either higher or lower acuity care settings.
This shift to move to funding healthcare systems on the basis of outcomes rather than inputs ensures payment
for success and incentives and reduces the risk of system failure. Further this system may readdress some of
the imbalances in the systems, which seem to benefit less complex care pathways. Rather than the current
system of unpaid overhead costs, capital by DRG permits an appropriate combination of capital resources to
be allocated for DRGs associated with case complexity and multiple diagnoses. Capital calculated for these
patient groups can promote better integration of services and use of substitution technologies sometimes as
alternatives to higher cost clinical interventions. Future research is being undertaken to identify capital costs
and develop investment strategies with a mix of IT, equipment and building infrastructure for each DRG.
3.6. Design Dialogues: A Collaborative Method for Design Driven
Innovation and Specification in Front End Planning
Professor Peter Frost, Chalmers University of Technology, Sweden
The key challenges in healthcare are to better capture and describe client and user needs in a complex
environment and to support change and organisational innovation through facility planning. A planning
process is needed where visions, requirements and spatial solutions can develop in parallel. There is a growing
need to create dynamic tools for variable planning objectives; along with creating new forms of interaction in
variable, team-based design processes in which multi professional teams (patients), client, builders and
experts all work together.
Professor Peter Frost described Design Dialogues, a research developed collaborative design method which
can be used in the early phases of building projects and has been applied in 50 consultancy projects in various
fields. Design Dialogues are planned as a carefully structured process with clear purpose, content and
expected results in each step. The work is carried out in a number of workshops in which various activities and
discussions are included in order to build knowledge and develop ideas. At the workshops, different tools such
as photo, video, game design and interactive computer tools are used to support dialogue. The architect
documents and interprets the comments and suggestions from the workshop groups. Based on
documentation, sketches and visualisations are developed, which form the basis for next steps. Proposals
develop gradually with varying level of detail and are successively incorporated into the ongoing dialogue. An
initial workshop is conducted with the project’s steering group before the work commences in order to define
the goals, objectives of the project along with identifying key issues, governance and design issues and setting
priorities. The expected results are determined along with future plans. The following methodology is adopted:
Workshop 1: Formulate qualities and flows - The first workshop often starts with a short video or photo
documentation of the existing premises; and participants comment upon them. This creates a gross list of
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problems and opportunities. Following this, the group works with building relationships and flows with the
help of "quality images" and images from the video.
Workshop 2: Design Games - In order to stimulate innovation and new approaches, inspirational material with
examples from other similar projects, are often used. A "design game" is conducted where the task is to build a
conceptual disposition proposal of an ideal future with their main functions, flows and need for connections.
Workshop 3: Evaluate alternatives - In this workshop, the architects visualise two alternative layout sketches
based on results of workshop 1 and 2. If necessary, the options are illustrated using simple digital 3D models
where one can walk around the premises and see the spatial consequences of various options. The
participants discuss, evaluate and consider the alternative layout sketches.
Workshop 4: Scenario and reconciliation - The layout sketches have been reconciled and processed into a
synthesis proposal before this workshop commences. A good tool to evaluate complex layouts is scenario
techniques. With the help of statistics and experience the participants prepare a business scenario of an
“average day" or "worst case". The work processes and flows are described in detail within the synthesis
proposal.
Professor Frost provided examples of projects in: ESS (European Spallation Source) Lund, Södersjukhuset
Stockholm Operating theatre + Emergency department, New Karolinska Solna (to develop programs and
conceptual block layouts for functions and flows) and Designing a Couplet Care level III NICU (using
Developmental Care and Design Dialogue). He further described an example where this methodology was
applied. Workshop 1 consisted of multi-disciplinary teams of doctors, nurses and managers to decide which
services can be retained and what changes were required within the units. Conceptual proposals were
developed based on initial findings. A workshop was also conducted with 8 parents of a total of 6 premature
infants treated in neonatal ICU during the period 2007-2010 and with a representative from the Parents
Association. Some participants also had experience from neonatal ICU at Karolinska Solna, Uppsala, and Lund.
A synthesis layout was generated based on the workshops along with a walk through. The various layout
scenarios were evaluated with the participants and a revised layout was created based on their input.
Professor Frost described Design Dialogue as part of the programming work for a collaborative design process
with multi professional teams working together. It is not a project management method. This approach differs
from other approaches as it based on design research and participatory design methodology and is integrated
on a big scale within a planning process. It promises to be more engaging, innovative, fast and stable than
traditional methods to develop organisational and business needs. He suggested in terms of future
development to merge standardised interactive multi-professional processes and standard rooms or units
based on Evidence Based Design. He concluded the session by introducing the recently established Research
Centre for Healthcare Architecture at Chalmers University.
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4. Challenges and Opportunities in
planning and delivering the health
estate
4.1. How Healthcare Infrastructure can and should contribute to making
a better civil society
Jonathan Erksine, Executive Director, European Health Property Network
Mr. Erksine introduced the session with a brief overview of the previous sessions and also highlighted the
importance of making information from such workshops more accessible. Excellence in clinical and medical
research and education is a key driver for high quality patient services. Case studies within Europe are
important for planning and designing; and collaboration across institutions is imperative for being at the
forefront of medical advancement. The planning and delivery of the healthcare estate is influenced by various
organisational, political, financial and environmental factors. There is an underlying need to depict best
practice in terms of design solutions, evidence of links between service models and the built environment and
the assessment of effectiveness of strategic planning. Environmental factors are increasingly important and
there is a drive to reduce carbon emissions in all areas including healthcare. EuHPN is also a partner in the Low
Carbon Building project.
4.2. Barriers to Innovation in Public Sector Procurement - the Case of Low
Carbon Healthcare Buildings
The Low Carbon Building (LCB) Healthcare Project Team: Angus Hunter
The speaker described the challenges that arise from increasing climate change targets and the consequential
impact on health and well being. The current EU commitment is to reduce carbon emissions by 20% by 2020.
As the healthcare sector owns and operates energy intensive facilities, energy and carbon will become more
expensive in the future. The existing facilities and services cannot deliver the scale or pace of change required.
New healthcare buildings need to be future proof and the existing buildings and facilities need to be
adaptable. Innovative solutions are important to deliver these changes, but such innovations are generally
slow to be adopted. Various barriers to innovation have already been identified: in some cases the solutions
just don’t exist in the market, or if they do, they are inadequate, unacceptable or expensive. One of the main
barriers to innovation is market failure; which includes lack of credible articulated demand, and lack of
knowledge in purchasing and driving innovation. Despite initial aspirations, projects often do not incorporate
innovative design solutions in the actual build and there is a notion that innovation is always expensive.
A proactive intervention is necessary to deal with these challenges, as the industry cannot be reliant only on
the market to deliver the relevant changes. The Lead Market Initiative (LMI) tool was developed to bring
innovative solutions to the market, in addition, the innovation policy initiative was launched in 2008, where EU
Member States, companies, NGOs, other stakeholders and the European Commission are working together to
reduce time-to-market of new products and services. Their focus is on six key sectors: sustainable
construction, protective textiles, bio-based products, recycling, e-Health and renewable energy. As part of this
programme, the Low Carbon Building-Healthcare project was recently launched. It is a three year, EC funded
project (2010-12), and is one of three LMI Public Procurement Networks. It has 6 partners across 4 countries:
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Department for Business Innovation and Skills (UK)
European Health Property Network (EuHPN)
Dutch Centre for Health Assets (Netherlands)
Directorate for Health Affairs (Norway)
Rawicz Hospital (Poland)
Department of Health (UK)
Their aim is to develop a European procurement network and to review current practice. There is also a plan
to undertake demonstrator pilots, to encourage sharing of good practice and mutual learning along with
disseminating lessons learnt. These pilots include the following case studies:
2
Netherlands: Erasmus Medical Centre, Rotterdam (new 185,000m hospital). Aim to reduce energy
consumption by 30%.
Norway: Builds on Norwegian Network for Low Energy Buildings. In dialogue with several hospitals in Norway.
2
Poland: Rawicz Hospital, 10,000m to meet new standards by 2012.
UK: Builds on Forward Commitment Procurement programme in health sector (ultra efficient lighting); in
dialogue with several NHS Trusts in England (more complex projects – FCP Plus). The following diagram (Figure
25) depicts the benefits of this program.
Figure 25. Programme Benefits
This program aims to benefit from mutual learning and encourages rapid spread of best practice in order to
promote global leadership and growth of European LCB Healthcare industries.
4.3. The Adverse Effects of the Absence of Return on Investment (ROI)
Calculations in the Public Sector in General and Healthcare in Particular
Dr Arne Bjornberg, Chief Operating Officer, Health Consumer Powerhouse
The healthcare industry contributes to about 9% of the GDP in many European countries, but it is not a capital
intensive industry. Traditionally investments in healthcare are determined based on ”affordability” rather than
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thinking about consequences of disinvestment. Dr. Bjornberg put forth the question of whether capital
investments in healthcare can be profitable in traditional ROI terms. He explained the importance of investing
in e-health as it improves patient safety, and increases patient empowerment, choice, self-management and
communication. It also serves as a support tool for clinical research and delivers better care in a shorter time
with better outcomes at a lower cost, along with a saving potential in healthcare budgets. E-health allows
information about the patients to be accessible to health professionals when required, thus enabling care to
be organised around the patient and not around institutions. On average, the value added time due to this is
around 3-10% of the total time. The potential gains in time and the improvement from the patient’s point of
view are shown in the following Figure 26.
Figure 26. Improvements in Patient Care Pathway
One of the main problems in the healthcare industry is that an IT investment postponed or not made is often
considered as a cost saving. The potentially huge return on IT investment is seldom recognised. He further
pointed out that there have been large differences in capital investment strategies for hospital equipments in
various countries. Furthermore, there is also a significant difference in treatment results and the two are
seldom co-related. There is a tendency for healthcare providers to supply all the hospitals or clinics with the
desired equipment. This was highlighted by the following example: in Bremerhaven, which has a population of
120,000, three general hospitals wanted to start a women’s clinic in 2006 and all three were unfortunately
successful in achieving this (an expensive solution which hindered the creation of a center of excellence).
Planners often do not take into account rent and depreciation and the effect of compensation by higher
revenue and lower operating costs. He concluded the session by highlighting the shortage of conventional
management skills in the public sector and the need to learn more from the management of businesses. He
proposed if healthcare was run like a business venture, it may be more efficient.
4.4.
Rebalancing Care Infrastruture in Hungary: Barriers to Success
Dr Miklos Szocska, Director, Health Service Management Training Centre, Semmelweis University, Budapest
Hungary has an insurance based health system which is gradually moving towards a tax based system. The
ageing index has grown rapidly from 64.5% to 109.9% from 1990 to 2009. Public spending in Hungary is 4.3%
which is much less than the EU average of 6.76%, which has subsequently led to a big gap in population health
status, compared with a number of other European countries. In Hungary, major problems arise from nontransparent budget setting, with inefficient spending. The healthcare delivery system is over centralised and
does not respond to the changing needs of the population. There are a number of emerging geographical and
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professional inequities due to political influence of resource allocation. The centrally controlled payment
system has been inefficient, and is further burdened by the existence of informal systems, coupled with
inadequate managerial capacity. Healthcare workers are largely dissatisfied with deteriorating working
conditions, low salaries, and decreasing prestige of their professions.
Strategic fund projects have a good potential for development in the Hungarian healthcare sector as these
focus on system efficiency gains rather than health gains. Such development resources are more suitable in
times of budget deficit consolidation or fiscal crisis. The development and implementation of a sustainable
health care reform takes time and commitment. Since 1990 Hungary has had 12 health ministers, frequent
changes in political direction, and consequential disruptions in the development process. Tactical project level
instruments cannot replace strategic policy level programmes; sustainability statements by decision makers
have proved to be useless in the short run. Some of the main constraints in utilising strategic funds include a
lack of horizontal coordination within a project scheme. There is no strategic integrative co-ordination
between primary care, outpatient care, and inpatient care. The complex bureaucratic processes reduce
transparency, generate dependence and expose organisations to a network of project consultants who add to
the expense of making grant applications.
There is a lack of expert capacity at various levels within the Ministry and municipalities that mainly considers
policy development and project administration. At the managing authority level there is lack of capacity and
most of the regional or county level muncipalities have to rely on external expertise in their development or
grant applications. A division of power exists between the Ministry of Health as the professional arm of policy
making and the Managing Authority as the development policy “supervisor” for the preparation and
implementation process. This division of power either works as a safeguard measure or causes political
paralysis. The existing culture within the preparation and development of projects is unsuitable, with the
deadlines for grant applications changing regularly and being regularly postponed. Dr. Szocska highlighted the
imbalance between the magnitude of infrastructure investment and the development of human resources.
This lack of coordination is not only a problem between the various levels of Structural Fund Investments, but
also across other domains of EU development activities.
4.5. Europe Matters: A Reflection of Trends and New Directions in
European (& EU) Capital Investment Strategies
Barrie Dowdeswell, Research Director, European Centre for Healthcare Assets and Architecture (ECHAA).
Healthcare has always been regarded as an important sector, but is also an essential contributor to the
fundamental economic drivers within society. In recent years there has been a growing need to demonstrate
the benefit of healthcare investment, in order to justify a “fair share” of resources. But the key issue has been
how to determine the value of investments in healthcare, since these comprise both tangible benefits and
other, less tangible ones.
In addition, healthcare systems face other challenges, such as continuing to reduce inequalities and managing
demographic and epidemiological transitions. It is also important to improve safety and quality, and to ensure
appropriate and equitable allocation of resources. Thus: policy makers are under pressure to ensure that
health care systems are efficient and deliver better value for money, with increased emphasis on relevant
health impact measures and analysis of return on investment.
Health inequalities exist within and between European countries. UK health has improved on average over the
past 50 years (Independent Inquiry into Inequalities in Health 2004, The Acheson Report, Department of
Health London) But in recent decades inequalities in health have either remained static or widened (based on
reduction in mortality rates). National reports highlighting how inequality and disadvantage damage health
have been published by other Member States including Sweden, Holland, Norway and Spain. INSERM (Institut
National de la Santé et de la Recherche Médicale) reports that mortality in France among blue-collar workers
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aged 45-59 years is 71% higher than among their white-collar peers. The "Independent inquiry into inequalities
in health" suggests that working independently can do little to reduce inequalities in illness, injury and life
expectancy. The EU in launching its communication Solidarity in Health: Reducing Health Inequalities in the EU,
October 2009 called for concerted action to reduce unnecessary ill-health and the shortened life span of
disadvantaged people in Europe; key policy areas must be addressed.
The needs of the chronically ill and ageing population along with the difficulty of managing public expectations
has actually increased conflict between the hospital centric model and the changing needs of the society.
Clinicians, managers and the public still tend to follow the hospital centric model, and hospitals using the
Private Finance Initiative (PFI) model of financing are built with debts retained that will be locked in for 20-30
years. This cycle persists, and hospitals are rarely if ever designed for significant adaption or disinvestment.
Current economic conditions may have ended an era of cumulative investment – capital and workforce and
health funding are collectively heading towards a zero sum game. There is an underlying need to move from
incrementalism towards “disinvesting to reinvest”. There is an acceptance that balance of healthcare provision
and future funding priorities must change but there is an equal reluctance to do it.
With increasing pressure on financial resources there is a drive to rethink the planning base and investment
framework. A more realistic critical mass is required for investment (or reinvestment) planning and sensitivity
to regional and area needs; the trend towards greater regionalisation seems inevitable. But some conflict
always exists between funding models and service cohesion. Ideology too often tends to overwhelm an
evidence based approach. For example, hospital datasets are often used to reinforce the need for new
hospitals rather than made available to wider interests to explore alternative models of care - this culture
should change. The current economic environment is bound by intersectoral tensions between the finance
ministry and other spending departments. The biggest single problem is health impact assessment - we do not
know what the health investment is delivering.
Spending in healthcare is often caught between a ”cost” or an ”investment”. From a finance ministry or
industry perspective the financial return on capital invested has stakeholder accountability and involves macro
debt management. The cost of capital is priced into services to account for depreciation as a charge against
income. Transparency over value for money has to exist to account for subsequent profit or loss. From a public
health perspective, health gain returns on capital invested include clinical outcomes, patient satisfaction,
societal value and health status of the population. Thus the term ”Return on Investment” suffers from
confusion where financial returns and health gain returns imply different meanings as seen above. These
principle are highlighted in a number of case studies from the recent EuHPN or European Observatory ”Capital
Investment for Health” study which provides a broad spectrum of case studies across the EU. The common
themes emerging were vision, innovation, discretion and cohesion. Mr. Dowdeswell further quoted the
communication from the Commission to the European Parliament, the Council, the European Economic and
Social Committee and the Committee of the Regions Brussels, 19.11.2009 COM(2009) 615 final. This depicts
the strong drive to promote PPP models, as one solution to the deficit recovery for Europe. The steady gains in
economic growth and job creation witnessed over the last decade have been wiped out by the economic crisis
of the past year. GDP fell by 4% in 2009, and industrial production dropped back to the levels of the 1990s and
23 million people or 10% of the active population are now unemployed. Public finances have been severely
affected, with deficits at 7% of GDP on average and debt levels at over 80% of GDP; two years of crisis erasing
twenty years of fiscal consolidation. Growth potential has also been halved during the crisis. Many investment
plans, talents and ideas risk going to waste because of uncertainties, sluggish demand and lack of funding.
The European Centre for Healthcare Assets and Architecture (ECHAA) seminar series also provided some
prespectives on the current health scenario. The critical catalyst for the global crash has been the asymmetry
between East (saving) and West (spending). In order to improve the current circumstances this situation has to
be addressed and rebalanced. There is a shift from cumulative growth to redistributive investment, the credit
crisis will inhibit capital availability for a decade or more for many sectors including health. The tipping point
has been the subprime crisis. Health has not generally attracted ‘stimulus’ investment. Rising revenue
spending has supported accumulation and has been reliant on high GDP growth levels. PPP (PFI) has been hit
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by the monoline collapse, but the debate about resolution is underway. The following Figure 27 depicts the
cycle of change and re-instates the importance of incorporating sustainability.
Figure 27. Cycle of Change
An emerging issue is to manage the risk of public investment retreat and move from crisis oriented to strategic
systems thinking. The risk management focus must become more strategic and systems based, and less crisis
orientated and individual provider based, in order to provide its greatest value to the organisation and the
patients those organisations serve. But it is important to learn lessons from Toyota and BP who failed to look
at the totality of the system. Part of the problem in making these shifts is performance management in
institutional based tiers and disease based tiers, but we do not know how to structure the reward system.
There is enormous reliance on various forms of structural funding due to legacy vs severe austerity and the
cost of borrowing along with the lack of tools and skills necessary to drive these changes. ECHAA is
contributing towards improving the effectiveness of healthcare investment by a piece of research which deals
with case study analysis along with process and competency improvement. Typically many types of funding
processes are judged on:
Delivery of programmes “on cost and on time”
Compliance with probity requirements
Within generally agreed overarching policy frameworks
The case studies show that hospitals were rewarded even if they performed badly, which would not occur in
an industry based environment.
The various funding models have certain predisposing effects:
Government Grants can be seen as “free” at point of hand over, but have had problems of historical
deficit based reward, monofocus, monoculture.
Leverage based Government Grants come with specific investment targeting, but need to avoid adhoc solutions, to recognise the underlying importance of relevant Master Planning and synergy, and
to acknowledge the principles of ROI.
Commercial loans secured on income collateral and debt servicing is biased towards financial
performance, economic sustainability, and raise issues of patient selectivity and quality.
Public Private Partnerships (NHS PFI) put undue emphasis on asset performance or utilisation rates,
issues of ownership, sustainability and cost. Full service (stakeholder) models were dependent on
stakeholder balance and influence, importance of contract frameworks and societal engagement.
In terms of use of structural funds, the speaker presented the following diagram (Figure: 28) which depicted a
review of competency needs.
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Figure 28. Capital Investment Competencies
The following mapping system (Figure 29) is under development: part of a new methodological tool kit which
will provide evaluation and decision criteria, and move towards more complete assessment of investment
value.
Figure 29. Capital Investment Value Assessment Toolkit
Europe 2020 will soon be dominating many of the agendas and its key priorities are:
Smart growth: developing an economy based on knowledge and innovation.
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Sustainable growth: promoting a more resource efficient, greener and more competitive economy.
Inclusive growth: fostering a high-employment economy delivering economic, social and territorial
cohesion.
The Commission is putting forward seven flagship initiatives to catalyse progress under each priority theme:
"Innovation Union" to improve research and innovation, ideas can be turned into products and services
that create growth and jobs
"Youth on the move"
"A digital agenda for Europe“
"Resource efficient Europe"
"An industrial policy for the globalisation era", notably for SMEs, and to support the development of a
strong and sustainable commercial base able to compete globally
"An agenda for new skills and jobs" to modernise labour markets
"European platform against poverty" to ensure social and territorial cohesion - benefits of growth and jobs
widely shared - and people experiencing poverty and social exclusion are enabled to live in dignity and
take an active part in society
They are also proposing country specific accountability and integrated guidelines to be woven in within the
structural fund policy. The speaker concluded that many European health trends are moving in the wrong
direction. But at the same time, there is a need to move from a cumulative to redistributive model of
investment. Better understanding of the measurable interaction between care models, workforce and capital
assets is required, along with the ability and will to act on the evidence. Sustainability is fast becoming one of
the critical decision criteria. Support for ”EU12” is available through Structural Funding policy but there is a
problem of focus and absorption and help is badly required.
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5. Recommendations
Grant Mills and Sameedha Mahadkar, Researchers, Health and Care Infrastructure Research and Innovation
Centre, Department of Civil and Building Engineering, Loughborough University
This workshop provided a highly insightful European perspective on the policies, principles, processes and
tools that shape healthcare infrastructure planning. It provided an exciting opportunity to meet with a wide
range of experts and to share global lessons. Most significant was the workshop’s focus on the relationship
between changes in services and health outcomes, the realisation of value and delivery of innovation and the
need for a more integrated approach to planning healthcare service and infrastructure. There was a clear need
to:
Identify Healthcare Planning Evidence that supports the relationship between clinical experience or
volume and clinical outcomes or quality. This evidence must be applied to projects to understand the
scale and distribution of healthcare infrastructure and to link demands and capacity;
Combine strong quantitative activity, space, time, cost and quality tools so that they can dynamically
respond to changing clinical technologies and enable infrastructures to scale based on varied
demands;
Better understand how population distributions, demographics and prevalence data can inform the
equitable distribution of care models that meet patient access and care needs;
Improve service life building value to ensure that infrastructure capital investment is assessed against
a complex set of competing multi-disciplinary value measures, metrics and evidence throughout an
integrated planning and design process;
Learn lessons and gather evidence from previous healthcare buildings to ensure that infrastructure
can make the most efficient and effective contribution to healing and patient or staff satisfaction;
Adopting an efficient estate management strategy which strives to achieve a balance between
investment opportunities and effective service provision;
Understand the interdependency and integration between levels of care, estates and transport
infrastructures and their impact on whole-system and whole-life value;
Improve adaptability and facilitate open and flexible decision making that can respond to changing
social, economic, political, technological and environmental factors;
Incorporating socially sustainable solutions within refurbished and new build that appropriately
quantify future levels of demand;
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Develop a dynamic stakeholder consultation approach, that has appropriate levels of stakeholder
engagement and robust participation approaches that manage stakeholder expectations and powers;
Apply advanced modelling and simulation approaches that improve the integration of multiparameter building and service performance data and inform whole system optimisation in
infrastructure planning and design and reduce whole system Green House Gases.
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The European Health Property Network is grateful to its hosts for the
2010 Workshop:
The European Health Property Network would also like to acknowledge the
support of the 2010 Workshop sponsors:
and